Monitoring Trends in Illicit Drug Use in Australia Wayne Hall School of Population Health, University of Queensland and Louisa Degenhardt and Natasha Sindicich National Drug and Alcohol Research Centre, University of New South Wales

Australian Monitoring of Illicit Drug Use 1: General Population National School Surveys: National School Surveys: Content Content Frequency Frequency Limitations Limitations Household surveys (2-3 yearly since 1985) Household surveys (2-3 yearly since 1985) trends in lifetime and past year use trends in lifetime and past year use –best for cannabis –less useful for cocaine, heroin and IDU Declining response rate: now under 50% Declining response rate: now under 50%

Patterns of illicit drug use in Australia, 2007 persons aged 20-29

Trends in recent use among Australian males years

Monitoring of Illicit Drug Use 2: Mortality & Morbidity Data Mortality data: drug related deaths Mortality data: drug related deaths –Good toxicology data on suspicious deaths –Available on line: best for opioids Morbidity data Morbidity data –Hospital separations that are drug-related dependence, OD, intoxication, psychoses dependence, OD, intoxication, psychoses Treatment seeking populations Treatment seeking populations –National Minimum Data Set –National Opioid Substitution Treatment data

Opioid Overdose Mortality per million Australian adults, years,

Trends in proportion of male overdose deaths

Trends in opioid overdose age at death

Cohort trends in opioid overdose death in males,

Age at which overdose deaths exceeded 5% of all deaths

Monitoring of Illicit Drug Use 3: Trends in Special Populations Drug Use Monitoring in Australia (DUMA) Drug Use Monitoring in Australia (DUMA) Established 1999 based on US ADAM Established 1999 based on US ADAM Quarterly urinalyses & surveys of arrestees in 5 states Quarterly urinalyses & surveys of arrestees in 5 states Illicit Drug Reporting System (IDRS) Illicit Drug Reporting System (IDRS) Developed Developed In operation in NSW since 1996 In operation in NSW since 1996 National study since 2000 National study since 2000 Ecstasy-related Drug Reporting System (EDRS) Ecstasy-related Drug Reporting System (EDRS) Developed 2000; in operation since 2001 Developed 2000; in operation since 2001 National study since 2003 National study since 2003

Aims of IDRS & EDRS Act as early warning systems to detect changing patterns of use and harm Act as early warning systems to detect changing patterns of use and harm Data on price, purity, and availability of illicit drugs Data on price, purity, and availability of illicit drugs Monitor patterns of use, trends & harms over time Monitor patterns of use, trends & harms over time Priorities for specialised/detailed research Priorities for specialised/detailed research Provide an evidence base for policy Provide an evidence base for policy

Drugs focused on IDRS Injecting Drug Users (IDRS) Heroin Cocaine Methamphetamine –Speed powder –Base –Ice/Crystal Cannabis Other opioids Diverted pharmaceuticals

Drugs focused on EDRS Regular Ecstasy Users (EDRS) Ecstasy Cocaine Methamphetamine –Speed powder –Base –Ice/Crystal MDA Ketamine GHB LSD

Methodology Three parts: Three parts: Drug user interviews Drug user interviews Key expert interviews Key expert interviews Indicator data Indicator data Data collected Australia wide on an annual basis Data collected Australia wide on an annual basis IDRS in NSW since 1996 and national since 2000 IDRS in NSW since 1996 and national since 2000 EDRS national data since 2003 EDRS national data since 2003

Sample criteria user survey Injecting Drug Users (IDRS) Regular Ecstasy Users (EDRS) Injected in the last 6 monthsEcstasy use in the last 6 months In the “market” for the past year Sampled from needle and syringe programs, outreach, clinics, snowballing Advertised in street press, music and clothing shops, universities and snowballing Around 100 participants from each jurisdiction

Surveys of IDU/REU Sentinel populations of polydrug users Sentinel populations of polydrug users Knowledgeable about: Knowledgeable about: drug prices & availability of drug prices & availability of opiates, amphetamine, cannabis, cocaine opiates, amphetamine, cannabis, cocaine ecstasy and related drug markets ecstasy and related drug markets emerging drugs: illicit or pharmaceutical emerging drugs: illicit or pharmaceutical Polydrug users whose drug use reflects: Polydrug users whose drug use reflects: availability & price of different drugs availability & price of different drugs changes in route of administration changes in route of administration new drug use, e.g. pharmaceuticals, OTC new drug use, e.g. pharmaceuticals, OTC

Key Experts Law enforcement officials Law enforcement officials Health workers Health workers NSEP and outreach workers NSEP and outreach workers Treatment staff Treatment staff Users groups Users groups Drug researchers Drug researchers Specialised knowledge complements Specialised knowledge complements user surveys and indicator data user surveys and indicator data

Leading Indicators Originally Originally law enforcement data on drug price & purity law enforcement data on drug price & purity Other survey data e.g. NSP attendees Other survey data e.g. NSP attendees Alcohol and Drug Information Service calls Alcohol and Drug Information Service calls Later added Later added Ambulance data on suspected overdoses Ambulance data on suspected overdoses On line coronial data on drug-related deaths On line coronial data on drug-related deaths Drug use among Sydney MSIC clients Drug use among Sydney MSIC clients

Annual meetings of researchers and policy makers Rationality is a social process Rationality is a social process Debate about data and its implications Debate about data and its implications Triangulation of IDRS data Triangulation of IDRS data Against experiences of key informants Against experiences of key informants Testing against other information Testing against other information Especially lagging indicators Especially lagging indicators Exploring alternative explanations Exploring alternative explanations

What has the IDRS shown: heroin use ? Heroin epidemic circa Heroin epidemic circa Younger users initiating via smoking Younger users initiating via smoking Increased purity & decreased price Increased purity & decreased price Rising fatal & non-fatal overdose rate Rising fatal & non-fatal overdose rate Public injecting Public injecting Abrupt reduction in heroin supply Abrupt reduction in heroin supply Start of 2001 in all states and territories Start of 2001 in all states and territories 40% decline in OD deaths in % decline in OD deaths in 2001 sustained thereafter sustained thereafter Brown Heroin available since 2006 Brown Heroin available since 2006

Frequency of NSW heroin use, ( source: NSW IDRS IDU surveys) Note: Maximum days = 180

Number of ambulance callouts to NSW heroin overdoses

Effects on Treatment Services More long term users entered MMT More long term users entered MMT “New” heroin users less often sought help “New” heroin users less often sought help Small increase in treatment seeking for amphetamines and cocaine Small increase in treatment seeking for amphetamines and cocaine

Changes in Crime Drug distribution became more covert Drug distribution became more covert Dealers sold other drugs, varying between states Dealers sold other drugs, varying between states In Adelaide, Brisbane and Melbourne: In Adelaide, Brisbane and Melbourne: –methamphetamines In Sydney In Sydney –cocaine injection in street-based sex workers Violent crime Violent crime short term increase in violent acquisitive crime in Sydney short term increase in violent acquisitive crime in Sydney Property crime Property crime short term increase in Sydney short term increase in Sydney then a long steady decline that has continued then a long steady decline that has continued

What has the IDRS shown about stimulant use ? Increased cocaine use in NSW Increased cocaine use in NSW confined to inner-city Sydney IDU confined to inner-city Sydney IDU increased purity & decreased price increased purity & decreased price More methamphetamine use since 2003 More methamphetamine use since 2003 Especially in ACT & Tasmania Especially in ACT & Tasmania Speed and crystal meth the most used forms Speed and crystal meth the most used forms Small increases in: Small increases in: Treatment seeking for problem use Treatment seeking for problem use Increased hospitalisations for psychoses Increased hospitalisations for psychoses

Cocaine use 1996 – 2008 (source: NSW IDRS IDU survey)

Harms related to opioid and amphetamine use (1) Overdose (ED; NSW only) Arrests (National) Source: Emergency Department Information System, NSW Department of Health Source:ABCI, 2001, 2002; ACC 2003, 2004 & 2005

Harms related to opioid and amphetamine use (2) Source: ABS Causes of Death Database; Degenhardt, Roxburgh, (2007a; 2007b) Source: National Hospital Morbidity Database; Roxburgh & Degenhardt (2006) Accidental deaths (National) Hospital separations (National)

Drug of choice, What has the EDRS shown about ERD markets (1)?

Recent use What has the EDRS shown about ERD markets (2)?

What don’t they tell us? Trends outside cities Trends outside cities General population patterns of use General population patterns of use sentinel groups targeted sentinel groups targeted The size of the drug market The size of the drug market how many users are there? how many users are there? Other research to address these issues Other research to address these issues

So what do they tell us? What’s new What’s new drugs drugs harms, extent of harms harms, extent of harms price, purity, availability price, purity, availability What’s the same since last year What’s the same since last year (or the year before…) (or the year before…) What we need to keep an eye on What we need to keep an eye on Where additional research is required to investigate the significance of any trend Where additional research is required to investigate the significance of any trend

Acknowledgements IDRS/EDRS a product of many hands IDRS/EDRS a product of many hands Original work at NDARC Original work at NDARC –Julie Hando; Lisa Maher; Shane Darke –their many successors Researchers in each jurisdiction Researchers in each jurisdiction Key Experts in Health & LE Key Experts in Health & LE Injecting Drug Users and Regular Ecstasy Users Injecting Drug Users and Regular Ecstasy Users

Further information IDRS and EDRS then click ‘Drug Trends’ 2008 reports were released on April 1, 2009.